AUTHORIZATIONFORRELEASEOFMEDICALINFORMATION
ExtendFertilityMedicalPractice
200West57thStreet,Suite1101
NewYork,NY10019
PatientName(Print)________________________________________
DateofBirth_______________
IauthorizetheofficeofExtendFertilityMedicalPracticetoreleasethefollowinghealthinformationtothe
physician/practice/facility/personindicatedbelow.PLEASECHECKALLTHATAPPLY.
☐LimitedNotes(includingFlowsheet,TreatmentPlan,Results)
☐Flowsheet(includesSonogramResultsandPrescriptions)
☐Consentformsforprocedures
☐Outsidelabresults
☐Other(specify):___________________________________________________________
OR
☐EntireMedicalRecord,includingmedicalhistory,physicalexams,testresults,freetextnotesabout
careprovidedandpatientdiscussions,decisionsandtreatmentsprovided,consentsforprocedure,and
othermedicalconsultationsusedtomakedecisionsaboutcareandtreatment.
AND indicate whether you authorize the release of:
☐GeneticsTesting
☐HIV/AIDS-RelatedInformation(includingHIV/AIDSTestResults
_________InitialHere
_________InitialHere
TherecipientofmyHIV-relatedinformationisprohibitedfromredisclosingsuchinformationwithoutmy
authorizationunlesspermittedtodosounderfederalorstatelaw.IunderstandthatIhavetherighttorequest
alistofpeoplewhomayreceiveorusemyHIV-relatedinformationwithoutauthorization.IfIexperience
discriminationbecauseofthereleaseordisclosureofHIV-relatedinformation,ImaycontacttheNewYorkState
DivisionofHumanRightsat(212)480-2493ortheNewYorkCityCommissionofHumanRightsat(212)3067450.
Authorizationforreleaseofinformationcoverstheperiodofhealthcarefrom_____________to
_____________.
Pleaseindicatethedateatwhichthisauthorizationwillexpire:
_________________________________________.
Authorization for Release of
Medical Information: 6.3
Created 2/1/2016; Updated 6/6/2016
212-810-2828
www.extendfertility.com
Whowillrelease/discloseinformation:
Name: ExtendFertilityMedicalPractice
Address:
200West57thStreet,Suite1101
City,State,Zip:NewYork,NY10019
Whowillreceiveinformation:
Name: _____________________________
Address:
_____________________________
City,State,Zip:_____________________________
Phone#:
_____________________________
Fax#: _____________________________
Email: _____________________________
FacilityName(ifapplicable):
_____________________________
Informationshouldbesentvia: ☐USPS(mail)
☐Email ☐Fax
Purposeorneedfortheinformationrequested:(OPTIONAL)
☐IndividualRequest
☐ReferraltoSpecialist
☐Insurance
☐TransferofCare
☐Other:___________________
Iunderstandthatmyrecordsareconfidentialandcannotbedisclosedwithoutmyauthorization,exceptwhen
otherwisepermittedbylaw.Treatment,payment,enrollmentoreligibilityforbenefits(asapplicable)willnotbe
conditioneduponmysigningofthisauthorizationform.
IunderstandthisconsentisvoluntaryandthatImayrevokethisauthorizationatanytime,excepttotheextent
thatactionbasedonthisconsenthasalreadybeentaken.Myrevocationmustbesubmittedinwritingto
ExtendFertilityMedicalPracticeat:200West57thSt.Suite110NYNY10019.
Iunderstandthatinformationusedordisclosedpursuanttothisauthorizationmaybedisclosedbytherecipient
andmaynolongerbeprotectedbythefederalHIPAAPrivacyRuleorstatelaw.
_____________________________________________________________________
PatientSignature
Date
FOROFFICEUSEONLY
Authorization for Release of
Medical Information: 6.3
Created 2/1/2016; Updated 6/6/2016
212-810-2828
www.extendfertility.com
Requestprocessedby:_____________________________________________________________________
Date_________________
Authorization for Release of
Medical Information: 6.3
Created 2/1/2016; Updated 6/6/2016
212-810-2828
www.extendfertility.com